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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED w (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 3OWMA9:�-J �SC► Citi-3110'c-I Lot Size3A' pM c, r�P Owner's Name Xiddress 0 5�� `ice Phone ��3Y r Contractor's Name W0License No. f �OO _Q34c TYPE OF WELL/PUMP: NEW WEL Phone WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYST M REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �f' DISPOSAL FLD. gp7PROP. LINEFOUNDATION AGRICULTURE WELL�06 OTHER WELLPITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation5' Domestic/Private Gravel Pack Dia. of Well Casing ❑ Tracy Type of Casing � Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ❑ irrigation ----Approx. Type of Grout '�` ! De ❑ Eastern �(top by Repair Work Done ❑ Type of Pump H.P, State Work pone Well Destruction ❑ Well Diameter Sealinf Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ' Installation will serve: 00 Residence, Commercial_ Other UJ available within 200 feet.} Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Water table depth Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size Q FILTER BED -❑ Distance to nearest: Well Foundation Pro party Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation'. Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the fallowing:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applican pt call for all-r-eq�uiirred inspe iu . Completeing o averse side. Signed ��"� +�' Title: 1 Date: FOR DEPARTMENT USE ONLY Application Accepted by Date r Area Pit or Grout Inspection by t j'f1v ^ }� Date t � f mal Inspection by Date Additional Comments: . o �k"` U 4, f Y v v+ ` ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED 1zli: C PERMIT NO. +EH 13-24{REV.1e183} 1`��EH 1426 � OQ r�7